JOHNSON 


- 


INAUGURj       .  IMTRJ     3AJ     ..  JKES 

_    lh       .   rtVIX  FEMORIS 


AM?  DIP 


jj£2_ 


Columbia  Stotoerm'tp 

intljeCttpofBrmgork 

College  of  Pfjpsiriang  anb  burgeon* 
Hibrarp 


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AN 


Inaugural  Cjrtsis 


CERVIX   FEMORIS. 


SUBMITTED  TO  THE  PUBLIC  EXAMINATION  OF  THE  TRUSTEES  AND  FACULTY   OF  MEDI- 
CINE OF  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS  OF  THE 


UNIVERSITY   OF   THE    STATE   OF  NEW   YORK. 
THOMAS  COCK,  M.D.,  President. 

Sox  tl)e  JDegrse  of  doctor  in  itteoicine., 

March.  12,  1857. 

BY  JOHN   GEO.   JOHNSON, 


OF    THB    STATB    OF    MA98ACDD8 


l*to  |;0il: 

BXILLER  &  HOLMAN,  PRINTERS,  CORNER  OP  CENTRE  AND  WHDHE  STREETS. 

1857. 


«SS 


-AO 


/p:<r, 


JAMES    R.    WOOD,    M.D., 


SURGEON     TO     BELLEVUE     HOSPITAL;     PRESIDENT     TO^THE     NEW     YORK 
PATHOLOGICAL    SOCIETY,    ETC.,    ETC. 


fins  firms   h  g*&uat*&, 

0  0  ^  ' 

As  an  humble  tribute  to  that  distinguished  Surgeon  for  his  noble  endeavors  to 

elevate  the  Profession  by  his  public  teachings  and  private  example,  and 

as  a  feeble  acknowledgment  of  the  debt  of  gratitude  due  to  him 

for  the  interest  he  has  manifested  in  the  advancement 

of  his  pupils  in  professional  information ;  by 

one  of  his  private  pupils, 

JOHN   GEO.  JOHNSON. 


-t 


Sv  Inba-Capsnlar  Jrofam  of  %  Cafe  Jfmork /'^  ^ 

Until  within  a  few  years,  much  diversity  of  opinion  has 
existed  upon  this  question.  Lately,  the  preponderance  of 
opinion  has  inclined  strongly  toward  the  affirmative.  In  the 
conviction,  however,  that  it  is  an  open  question,  we  desire  to 
submit  to  the  profession  the  results  of  our  investigation  of 
the  subject. 

The  first  question  which  presents  itself  is — Can  intra-cap- 
sular  fractures  be  diagnosed  with  certainty  during  the  life  of 
the  patient  ? 

Fractures  of  the  cervix  femoris  present  themselves  in  three 
varieties : — 1.  Those  entirely  within  the  capsular  ligament. 
2.  Those  entirely  without  the  capsular  ligament.  3.  Those 
partly  within  and  partly  without  the  capsular  ligament. 

The  subjective  symptoms  are  : — 1.  Pain.  2.  Loss  of  vol- 
untary motion.  The  objective  symptoms  are  : — 1.  Swelling 
and  deformity  at  the  hip.  2.  Approximation  of  the  tro- 
chanter major  to  the  anterior  superior  spinous  process  of  the 
ilium.  3.  Shortening.  4.  Crepitus.  5.  Eversion.  6.  Forma- 
tion of  callus.  7.  The  direction  in  which  the  force  is 
applied. 

It  is  hardly  necessary  to  refer  to  the  first  of  the  subjective 
symptoms  as  a  means  of  diagnosis,  for  in  all  cases  of  fracture 
of  the  cervix  femoris,  there  is  more  or  less  injury  to  and 
laceration  of  the  soft  parts — and,  consequently,  pain. 

It  is  generally  admitted  that  in  all  these  cases  the  patient 
feels  pain  in  the  whole  vicinity  of  the  joint. 

2.  Loss  of  voluntary  motion  exists  in  all  fractures  of  the 
cervix  femoris  where  there  is  displacement,  whether  the 
fracture  is  within  or  without  the  capsule.  The  only  excep- 
tion is  in  cases  of  impacted  fractures,  where  the  shaft  of  the 
bone  is  driven  into  the  cancellated  portion  of  the  head,  in 
which  cases  the  power  of  voluntary  motion  may  still  remain. 

Of  the  objective  signs,  the  amount  of  shortening  immedi- 
ately attendant  on  the  injury  has  been  insisted  upon  as  the 
most  conclusive  in  the  diagnosis  of  intra  from  extra-capsular 
fractures. 

Those  that  insist  that  they  can  distinguish  between  these 
kinds  of  fractures  during  the  life  of  the  patient,  maintain 
that  the  amount  of  immediate  shortening  in  the  cases  of 


extra-capsular  fractures  is  so  much  greater  than  in  intra-cap- 
sular  fractures,  as  to  furnish  conclusive  evidence  as  to  which 
class  the  fracture  belongs.  First,  they  maintain  that  imme- 
diate shortening  is  greater  in  extra-capsular  fractures,  from 
physiological  principles ;  second,  as  a  matter  of  experience. 
The  physiological  reason  is,  that  the  cervix  femoris  is  sur- 
rounded by  a  capsular  ligament,  which,  in  health,  is  ex- 
tremely powerful,  and  closely  embraces  the  head  and  cervix  ; 
thereby  preventing  the  shaft  from  slipping  so  far  in  intra  as 
in  extra-capsular  fractures.  If  the  capsule  was  in  every  case 
uninjured,  this  would  be  satisfactory ;  for  it  must  be  admitted 
that  the  capsular  ligament  is  very  strong,  and  acts  power- 
fully in  retaining  the  fractured  parts  in  their  places.  If,  how- 
ever, the  capsular  ligament  is  torn,  the  shaft  of  the  bone 
may  slip  through  the  rent,  and  thus  afford  an  amount  of 
shortening  as  great  as  in  cases  of  fractures  entirely  without 
the  capsule.  All  authorities  admit  that  laceration  of  the 
capsule  may,  and  often  does,  occur.  Again,  if  the  head  of 
the  femur  is  comminuted,  shortening  to  an  indefinite  extent 
may  occur.  The  head  of  the  femur  may  be  comminuted,  as 
this  fracture  usually  occurs  in  persons  past  the  prime  of 
life,  when  all  the  bones  are  fragile.  Further,  we  can  not 
diagnosticate  oblique  intra-capsular  from  transverse  extra- 
capsular fractures,  for  it  is  quite  impossible  to  feel  the  direc- 
tion of  the  fracture,  imbedded  as  it  is.  Again,  the  shock  is 
sometimes  so  great  as  to  cause  a  paralysis  of  the  muscles, 
and  in  these  cases  the  shortening  does  not  immediately  occur, 
even  though  the  fracture  be  extra-capsular.  The  fracture 
may  also  be  impacted,  and  yet  extra-capsular.  In  these 
cases  there  will  not  be  as  much  immediate  shortening,  as 
is  claimed  for  all  cases  of  extra-capsular  fractures. 

From  these  considerations,  we  conclude  that  unless  the 
condition  of  the  capsule,  or  the  precise  nature  of  the  frac- 
ture can  be  determined,  the  amount  of  shortening  is  not  a 
diagnostic  mark  to  be  relied  on. 

2.  Opinion  of  Authorities. — It  is  surprising  to  find  the 
amount  of  difference  among  authorities  upon  this  point. 
The  most  eminent  surgeons,  not  of  this  country  alone,  but 
English,  Irish,  and  French,  hold  directly  opposite  opinions. 

Sir  Astley  Cooper  says,  that  intra-capsular  fractures  gives 
the  greatest  amount  of  shortening.  Mr.  Stanley  is  opjjosed  to 
him.  He  states  that  extra-capsular  fractures  have  the  great- 
est shortening.  Amesbury  claims  the  greatest  shortening 
for  intra — and  Earle,  for  extra-capsular  fractures.     Robert 


Wm.  Smith,  of  Dublin,  claims  the  greatest  shortening  for 
extra-capsular ;  while  Chassaignac,  and  Vidal,  (de  Cassis) 
are  opposed  to  Desault,  Boyer,  Dupuytren,  and  Cloquet. 

How  can  these  contradictory  opinions  be  reconciled  or  har- 
monized ?  Only  by  considering  that,  in  some  instances,  the 
intra-capsular  fractures  have  given  the  greatest  amount  of 
shortening,  and  in  other  instances  the  extra-capsular  fractures 
give  the  greatest  shortening ;  and  that  the  surgeons  who 
have  seen  the  cases  of  the  first  class,  hold  the  opinion  that 
extra-capsular  shortening  is  the  greatest ;  while  those  who 
have  seen  cases  of  the  second  class,  hold  the  opinion  that 
intra-capsular  shortening  is  the  greatest ;  accepting  this,  as 
the  true  explanation,  and  there  is  none  other  we  can  accept 
without  charging  either  the  one  side  or  the  other  with  ignor- 
ance or  with  intention  to  mislead,  (neither  of  which  charges 
we  are  willing  to  make,)  we  are  compelled  to  conclude  that 
this  symptom  does  not  present  itself  with  sufficient  regu- 
larity to  be  of  weight  as  a  diagnostic  sign.  This  is  the  opinion 
entertained  by  the  French  Surgeon,  M.  Eodet,  who  says : — 
"  Cette  opposition  formelle  entre  les  opinions  de  ces  grands 
chirurgiens  vient  sans  doute  de  ce  qu'il  n'y  a  rien  de  constant 
dans  le  degre  du  raccourcissement,  qui  accompagne  de  ces 
deux  espices  des  fractures."  With  this  difficulty,  both  in 
theory  and  in  experience,  we  are  compelled  to  exclude  the 
amount  of  shortening  as  diagnostic  of  the  character  of  the 
fracture. 

Crepitus. — This  will,  depend  on  two  conditions  :  first, 
whether  there  is  anything  interposed  between  the  ends  of 
the  bone,  as  muscle,  capsular  ligament,  etc.,  to  prevent  the 
rubbing  of  the  ends  together  ;  second,  whether  there  is  im- 
paction. If  there  is  no  impaction,  and  nothing  interposed 
between  the  ends  of  the  bones,  there  is  no  reason  why  crepi- 
tus should  not  occur,  whether  the  fracture  is  intra  or  extra- 
capsular. 

Eversion. — This  will  depend,  if  the  fracture  is  intra-cap- 
sular, much  on  the  amount  of  laceration  of  the  capsule.  If 
the  capsule  is  lacerated,  there  is  no  reason  why  the  foot  may 
not  be  everted  as  fully  as  in  cases  of  extra-capsular  fractures. 
Until  it  is  determined  whether  there  is,  or  is  not,  laceration 
of  the  capsule,  it  is  certain  that  we  can  not  make  the  amount 
of  eversion  a  diagnostic  sign. 

Again,  if  the  fracture  is  extra-capsular  and  impacted,  there 
may  be  as  little  eversion  as  in  cases  of  intra-capsular  frac- 
ture, where  the  capsule  is  not  lacerated.     So,  whether  we 


8 

have  intra-capsular  fracture  with,  laceration  of  the  capsule, 
or  extra-capsular  fracture  without  laceration;  whether  we 
have  intra-capsular  fracture  without  laceration,  or  extra-cap- 
sular fracture  with  impaction,  we  can  not  form  a  diagnosis 
from  the  eversion. 

Callus. — It  has  been  thought  that  the  existence  of  cal- 
lus furnished  a  means  of  diagnosis,  because  there  would  be 
no  callus  formed  around  the  ends  of  the  bone,  if  the  frac- 
ture was  intra-capsular.  This  is  true ;  there  is  no  callus 
formed  within  the  capsule,  but  there  is  a  formation  of  callus  in 
cases  of  intra-capsular  fracture.  The  callus  is  formed  pre- 
cisely where  the  law  that  governs  plastic  exudations  would 
teach  us  to  look  for  it,  viz. :  external  to  the  capsule,  where 
there  are  tissues  capable  of  effusing  it.  It  is  effused  external 
to  the  capsule  precisely  where  it  is  effused  in  cases  of  extra- 
capsular  fracture.  This  fact  is  beautifully  shown  in  the  spe- 
cimen of  intra-capsular  fracture,  now  in  the  possession  of  Dr. 
William  H.  Van  Buren,  of  this  city.  A  minute  description 
of  which  will  hereafter  be  given.  The  simple  formation  of 
callus,  therefore,  can  not  be  considered  a  diagnostic  sign  of 
extra-capsular  fracture,  as  it  may  be  found  in  the  same  place 
in  both  kinds  of  fracture. 

Approximation  of  the  Trochanter  Major  to  the  Anterior 
Superior  Spinous  Process  of  the  Ilium. — This  can  not  be  a  diag- 
nostic sign,  for  there  will  be  approximation  in  every  case  of 
fracture  of  the  cervix,  and  the  degree  of  approximation  will 
depend  on  the  direction  of  the  fracture  ;  an  oblique  fracture 
giving  us  more  approximation  than  a  transverse ;  and  this 
rule  will  hold  true,  whether  it  is  an  intra  or  extra-capsular 
fracture. 

Swelling  and  Deformity  at  the  Hip. — This  will  occur  in 
both  cases  ;  the  amount  of  deformity  depending  on  the  direc- 
tion of  the  fracture. 

M.  Kodet  having  come  to  the  conclusion,  that  none  of  thesa 
signs  were  diagnostic,  rejected  them ;  and  maintained  thet 
the  direction  in  which  the  force  was  applied  was  the  only 
diagnostic  sign  ;  and  that  the  fracture  will  be  intra  or  extra- 
capsular, oblique  or  transverse,  according  as  the  force  has 
been  received  in  a  vertical,  lateral,  or  transverse  direction. 
Mr.  Smith  thus  sums  it  up  : 

Force  acting  vertically, Fracture  will  be  oblique,  and  intra-capsular. 

antero-laterally, transverse,  and  intra-capsular. 

postero-laterally, . . .  mixed, 

transversely, extra-capsular. 


Thus,  if  the  person  fell  upon  the  knees,  we  should  have  the 
first  class,  oblique  and  intra-capsular  ;  and  in  regard  to  this 
argument,  Mr.  Smith,  of  Dublin,  makes  the  following  very- 
just  remarks  :  "  With  respect  to  Rodet's  diagnostic  sign,  it 
will  be  admitted  as  a  general  principal,  that  the  mode  of  appli- 
cation of  the  force  and  the  direction  in  which  it  acts,  will 
determine  the  situation  and  direction  of  the  fracture  ;  but  I 
contend  that  it  is  seldom  available  in  practice  in  determining 
the  seat  of  a  fracture  of  the  neck  of  the  femur  with  respect 
to  the  capsule,  for  it  would  be  extremely  difficult,  if  not  im- 
possible, in  the  generality  of  cases,  to  obtain  from  patients 
a  description  of  the  direction  in  which  the  force  was  applied, 
as  accurate  as  would  be  necessary  before  we  could  avail  our- 
selves of  it  as  a  means  of  diagnosis.  It  is  not  probable  that 
a  person  of  advanced  age,  who  had  just  suffered  so  severe  an 
injury  as  fracture  of  the  neck  of  the  thigh  bone,  would  be 
able  to  inform  us  whether  the  shock  was  sustained  by  the 
external  surface  of  the  trochanter,  or  whether  there  was  a 
deviation  anteriorly  or  posteriorly  from  a  directly  lateral  fall." 
(Smith  on  Fractures,  Page  21.)  It  might  be  quite  impossi- 
ble to  determine  the  point  of  injury  from  an  examination  of 
the  hip,  as  it  may  have  been  so  protected  by  the  clothes,  that 
no  ecchymosis  occurred,  or  the  contusion  and  ecchymosis 
maybe  so  extensive  as  to  lose  all  value  as  indications  of 
the  precise  spot  of  the  application  of  the  force.  Mr.  Smith 
also  gives  an  instance  (page  21)  in  which,  according  to  this 
rule,  we  should  have  an  extra-capsular  fracture,  and  in  which 
dissection  proved  that  the  fracture  was  intra-capsular.  So 
much  for  this  diagnostic  sign,  beautiful  in  theory,  but  value- 
less in  practice. 

I  have  thus  reviewed  each  of  these  symptoms  of  fracture. 
They  are  all  extremely  obscure,  and  the  one  upon  which  the 
'  greatest  stress  has  been  laid — shortening — must  be  excluded 
altogether.  Taken  separately,  no  one  of  them  will  enable 
us  to  form  a  diagnosis ;  taken  collectively,  there  are  so  many 
different  conclusions  that  may  justly  be  deduced  from  them, 
that  no  positive  diagnosis  can  be  given  between  the  two 
kinds  of  fracture  during  the  life  of  the  patient. 

If  this  difficulty  attends  the  diagnosis  of  the  two  extreme 
classes  of  extra  and  intra-capsular  fractures,  still  greater  dif- 
ficulty must  attend  the  diagnosis  of  the  third  class,  which  is 
a  mixture  of  the  other  two,  partly  intra  and  partly  extra- 
capsular ;  and  when  we  come  to  diagnose  this  third  class 
from  the  other  two,  it  is  impossible.  As  no  accurate  opinion 


10 

can  be  formed  of  the  precise  nature  of  the  injury  during  the 
life  of  the  patient,  so  no  conclusion  can  be  drawn  as  to  the 
osseous  or  non-osseous  union  of  fractures  within  the  capsule 
from  those  patients  who  recover.  This  limits  the  decision 
of  the  question  to  the  conclusions  derived  from  an  examina- 
tion of  post-mortem  specimens. 

Before  entering  on  that  question,  it  may  not  be  improper 
to  consider  the  probability  of  the  osseous  union  of  intra-cap- 
sular  fractures,  in  the  view  of  the  anatomical  and  pathological 
conditions  existing.  The  first  point  is  the  effectjrf  the  injury 
on  the  capsule. 

Violence  sufficient  to  fracture  the  cervix  femoris,  must 
be  sufficient  to  cause  injury  to  the  synovial  membrane  of 
the  capsule.  The  result  of  that  injury  will  be  inflamma- 
tion of  the  synovial  membrane,  and  the  result  of  that  in- 
flammation will  be  the  effusion  of  a  superabundance  of  sy- 
novial fluid ;  or,  if  the  inflammation  continues  long  enough, 
of  plastic  lymph.  Now,  when  the  synovial  fluid  is  poured 
out,  there  must  be  distention  of  the  capsule  by  it,  and  if  this 
occurs,  then  there  must  be  separation  of  the  ends  of  the  bone, 
for  they  are  attached  to  the  capsule.  If  the  ends  of  the  bone 
are  separated,  we  can  not  have  osseous  union ;  for  even  the 
most  ardent  advocate  of  osseous  union  (R.  W.  Smith,  of  Dub- 
lin) claims  it  only  in  cases  of  impacted  fractures.  Now,  as 
long  as  the  inflammatory  action  continues,  so  long  shall  we 
have  synovitis,  effusion,  distention  of  the  capsule,  and  con- 
sequent separation  of  the  ends  of  the  bone.  If  the  inflam- 
matory action  ceases,  we  shall  not  have  union  by  bone,  for 
the  first  thing  nature  does  is  to  get  up  an  inflammatory 
action  in  and  around  the  ends  of  the  bone,  whereby  plastic 
exudation  is  poured  out.  That  we  do  have  synovitis  in  all 
cases  of  intra-capsular  fractures  is  evident  from  the  autop- 
sies, for  the  capsule  is  always  reported  thickened.  This 
thickening  is  evidently  due  to  inflammation  of  the  synovial 
membrane,  so  long  continued  that  not  merely  synovial  fluid 
had  been  effused,  but  plastic  lymph,  and  that  lymph  had  be- 
come organized. 

2.  There  is  no  sufficient  means  left,  after  the  fracture, 
to  nourish  the  head  of  the  bone,  and  furnish  material  for 
ossific  union.  The  only  possible  means  of  nourishing  the 
head  of  the  bone,  are  four  in  number  : — 1.  From  the 
branches  of  the  nutrient  artery  of  the  femur.  2.  From 
the  periosteum.  3.  From  the  synovial  membrane.  4. 
From  the  vessels  of  the  ligamentum  teres  : — 1.  If  the  bone 


11 

is  fractured,  the  probability  is  that  the  branches  of  the 
nutrient  artery  are  torn  from  the  head  of  the  femur.  2.  The 
periosteum .  will  probably  be  torn,  because  it  is  the  most 
delicate  upon  the  head  and  cervix.  3.  The  synovial  mem- 
brane would  produce  synovial  fluid  and  lymph,  but  not 
ossific  matter.  4.  The  vessels  of  the  ligamentum  teres  are 
so  small  as  to  be  imperceptible  to  the  unassisted  eye,  and  it 
is  not  possible  that  these  should  be  able  to  carry  a  sufficient 
amount  of  nutrition  to  support  the  bone,  and  afford  ossific 
union.  Grant,  for  the  sake  of  argument,  that  the  vessels  of 
the  ligamentum  teres  were  capable  of  performing  this  func- 
tion. If  they  did  perform  it,  they  would  become  much 
enlarged  from  this  increased  action,  in  the  same  manner  that 
the  anastomotic  vessels  are  enlarged -in  the  case  of  aligated 
artery  ;  but  in  every  one  of  these  cases,  of  so-called  osseous 
union,  where  the  ligamentum  teres  has  been  spoken  of,  it 
has  been  described  as  natural.  If  it  was  natural,  then  its 
vessels  could  not  have  performed  this  increased  function.  If 
it  was  not  natural,  then  the  notes  have  not  been  faithfully 
reported. 

3.  Another  difficulty  in  the  way  of  osseous  union  is  to  be 
found  in  the  difficulty  of  maintaining  the  ends  of  the  bone 
in  coaptation.  Nature's  splint  does  not  work  here  ;  there  is 
no  provisional  callus  around  the  ends  of  the  bone  to  main- 
tain them  in  apposition.  There  is  effusion  into  the  capsule,  so 
that  no  external  splint  can  be  applied  which  will  be  able  to 
control  the  upper  end  of  the  fractured  bone ;  for,  if  it  is  firmly 
applied,  the  pressure  will  increase  the  synovitis  ;  if  it  is  not 
firmly  applied,  it  is  of  no  use. 

We  conclude,  therefore,  that  bony  union  of  the  intra-cap- 
sular  fracture  does  not  occur,  for  the  following  reasons  : 

1.  The  separation  of  the  ends  of  the  bone  by  the 
synovitis,  which  synovitis  continues  so  long  as  there  is 
inflammatory  action  in  the  part.  2.  The  lack  of  tissues 
capable  of  producing  ossific  matter.  3.  The  lack  of  means 
of  nourishment.  4.  The  impossibility  of  retaining  the  bone 
in  coaptation. 

Before  leaving  this  part  of  the  argument,  another  point 
must  be  briefly  considered,  because  some  writers  lay  great 
stress  upon  it.  It  is  the  "Argument  from  Analogy;"  or, 
the  bony  union  of  fractures  of  bones  within  synovial  mem- 
branes, as  in  fractures  of  the  patella  and  olecranon.  This 
argument  seems  to  many  to  be  conclusive,  and  it  is  urged, 
as  such,  by  men  of  eminence  in  their  profession.     A  slight 


12 

examination  will,  however,  show  points  of  difference  suf- 
ficient to  destroy  all  analogy  and  all  arguments  derived  from 
analogy.  1.  The  patella  is  not  a  part  of  the  skeleton.  It  is 
a  sesamoid  bone  developed  in  the  tendon  of  the  quadriceps 
extensor  muscle,  to  afford  this  muscle  greater  leverage. 
2.  It  is  a  flat  bone,  while  the  head  of  the  femur  is  sphe- 
roidal. 3.  It  is  more  fully  nourished  than  the  head  of  the 
femur.  The  head  of  the  femur,  in  cases  of  fracture,  derives 
its  nourishment  entirely  through  the  ligamentum  teres,  a 
small  rounded  tendon  ;  while  the  flat,  strong  band  of  tendi- 
nous fibres,  composing  the  ligamentum  patella,  passes  over 
the  entire  length  of  the  patella.  This  ligament  is  so  large 
that  it  would  be  more  fitly  denominated  the  tendon  of  the 
quadriceps  extensor  muscle.  The  whole  anterior  surface  is 
covered  with  synovial  membrane,  and  there  is  a  fold  of  syno- 
vial membrane  reflected  behind  the  patella,  termed  the  liga- 
mentum mucosum.  The  knee  joint  is  the  largest  joint  in 
the  whole  body,  and  the  patella  being  a  flat  bone,  there  is  a 
greater  amount  of  surface  in  proportion  to  the  size  of  the 
bone  to  receive  nourishment  from  the  synovial  membrane  and 
fluid,  than  is  the  case  in  the  head  of  the  femur.  Again,  the 
knee  joint  is  more  abundantly  nourished  than  the  acetabu- 
lum. We  find  five  arteries  of  considerable  size  passing  to 
the  joint — so  large  as  to  be  described  by  anatomists.  They 
are  the  two  upper  articular  arteries,  the  two  lower  articu- 
lar arteries,  and  the  middle  articular  artery.  Of  these,  the 
middle  branch  or  external  articular  artery,  goes  directly  to 
the  patella;  and  the  lower  internal  articular  artery  sends 
branches  directly  to  that  bone.  These  five  arteries  form 
a  net- work  of  vessels  at  the  front  and  sides  of  the  joint, 
so  that  the  patella  has  an  abundant  supply  of  blood  in 
cases  of  fracture — unless  these  vessels  are  destroyed.  Most 
fractures  of  the  patella  occur  from  a  sudden  strain,  rather 
than  from  direct  violence,  so  that  in  the  majority  of  cases 
there  will  be  abundant  nourishment  to  the  fractured  patella. 
The  olecranon  has  scarcely  more  analogy  with  the  cervix 
femoris  than  the  patella.  Instead  of  being  attached  by  a  small 
ligament,  like  the  ligamentum  teres,  there  is  the  powerful  liga- 
ment of  the  triceps  extensor  muscle — a  tendon  far  more  capa- 
ble of  supporting  a  bone  as  large  as  the  head  of  the  femur  than 
the  ligamentum  teres.  But  it  has  no  such  work  to  perform. 
The  olecranon  has  other  and  ampler  sources  of  nourishment, 
being  covered  on  one  side  by  cartilage,  and  on  the  other  by 
the  synovial  membrane  of  the  joint.     The  synovial  mem- 


13 

brane  of  the  elbow  joint  is  far  larger,  in  proportion  to  the 
size  of  the  olecranon,  than  is  that  of  the  hip  joint  to  the  size  of 
the  head  of  the  femur.  We  regard  it  as  established,  there- 
fore, that  the  prospects  of  union  are  far  more  favorable  in 
cases  of  fracture  of  the  patella  and  olecranon,  than  in  cases  of 
fracture  of  the  cervix  femoris.  But  what  results  are  obtained 
in  cases  of  fracture  of  the  patella  and  olecranon  ?  Almost  in- 
variably union  by  ligament.  The  union  by  bone  is  the  ex- 
ception, and  so  rare  an  exception  that  the  specimens  are 
preserved  in  museums,  as  curiosities.  These  reasons  place 
the  improbability  of  union  beyond  a  reasonable  doubt. 

Again,  the  non-union  of  cases,  where  everything  was  favor- 
able, affords  a  strong  probability  that  union  does  not  occur. 
I  will  quote  two  of  these  cases  for  illustration. 

I  am  indebted  to  Dr.  James  E.  Wood,  of  this  city,  for  the 
following  history,  which  he  has  kindly  furnished  me,  of  a 
case  which  occurred  in  his  own  practice,  and  I  take  great 
pleasure  in  acknowledging  the  favors  I  have  received  from 
him,  both  in  the  privileges  of  his  museum  and  also  in  his 
library,  and  the  facilities  he  has  afforded  me  in  the  investi- 
gation of  this  subject: 

Case  1. — History. — M.  J.,  a  young  lady,  eet.  16  years ;  of 
vigorous  constitution;  perfectly  free  from  any  constitu- 
tional taint  either  of  scrofula,  syphilis,  or  cancer;  was  caught 
between  the  wheels  of  two  carriages,  the  one  stationary,  the 
other  in  motion.  The  blow  was  received  directly  on  the  tro- 
chanter major  of  the  right  side.  The  symptoms  which  pre- 
sented themselves  showed  conclusively  that  there  was  a 
fracture.  There  was  shortening,  loss  of  voluntary  motion, 
and  eversion ;  by  placing  the  finger  on  the  trochanter  major, 
and  the  thumb  in  the  groin,  a  well-marked  crepitus  could  be 
felt  on  extension  and  rotation  being  made.  There  was  no 
laceration  or  other  complication  of  the  injury.  She  was 
placed  on  Amesbury's  splint,  with  side  splints  accurately 
adjusted,  and  eveiy  precaution  taken  to  ensure  a  perfect 
union.  The  limb  was  kept  on  this  splint  without  being  dis- 
turbed for  six  weeks.  At  the  end  of  that  time,  it  was  taken 
from  the  splint,  and  examined  with  care.  The  signs  of  frac- 
ture still  remained;  the  limb  was  replaced  on  the  splint,  and 
the  dressings  as  before ;  everything  was  attended  to  in  the 
general  management  of  the  case  which  the  doctor  thought 
would  be  conducive  to  perfect  union.  The  patient  was 
kept  for  three  weeks  longer  on  the  splint,  which  was  then 
removed.     It  was  found  that  there  was  no  union.     Patient 


14 

lived  for  three  years,  and  was  so  lame  that  she  was  always 
obliged  to  use  a  crutch  in  walking.  At  the  expiration  of 
three  years  she  died  of  an  acute  disease. 

Post-Mortem  Examination. — On  examination  of  the  cervix 
femoris,  it  was  found  that  there  had  been  a  transverse  frac- 
ture of  the  bone  just  at  the  junction  of  the  head  and  neck. 
The  head  of  the  bone  was  still  attached  to  the  acetabulum  by 
the  ligamentum  teres.  The  process  of  absorption  had  been 
going  on,  and  the  head  of  the  bone  had  already  been  ab- 
sorbed below  the  level  of  the  acetabulum,  and  what  remained 
was  soft  and  spongy,  easily  broken  with  the  handle  of  the 
scalpel.  The  neck  of  the  bone  was  rounded  off,  and  covered 
with  a  fibrous  deposit.  This  was  not  a  case  of  diastasis,  as 
has  been  suggested  by  an  eminent  surgeon,  who  judged  sim- 
ply  from  the  age  of  the  patient.  She  was  full  sixteen  when 
the  accident  happened,  and  over  nineteen  when  she  died. 

Remarks. — This  case  makes  a  very  strong  argument  against 
union  by  bone.  Here,  every  circumstance  was  favorable. 
The  age  of  the  patient,  her  constitution,  the  immediate  diag- 
nosis of  a  fracture,  and  the  subsequent  treatment,  were 
favorable  to  osseous  union,  if  it  were  possible  that  such 
union  could  take  place  under  any  circumstances  where  the 
fracture  was  within  the  capsule.  She  was  not  an  old  patient, 
past  the  prime  of  life,  in  whom  the  vital  energies  were  nearly 
exhausted,  as  .are  most  of  the  patients  in  whom  osseous 
union  is  claimed  to  have  taken  place,  but  at  the  most  vigor- 
ous period  of  life,  just  after  ripening  womanhood  has  given 
full  strength  and  power  to  all  her  functions ;  a  period  when 
nature  is  prodigal  in  her  endeavors  to  aid,  and  when  her  re- 
cuperative powers  are  the  strongest.  She  was  not  broken 
down  by  constitutional  disease,  produced  either  by  her  own 
or  her  parents'  errors,  but  in  perfect  health,  free  from  all 
constitutional  taint,  either  of  scrofula,  syphilis,  or  cancer. 

There  was  no  mistake  in  the  diagnosis  of  the  case,  as  in 
one  of  Mr.  Smith's  so-called  cases  of  osseous  union.  Here 
the  diagnosis  was  made  at  once,  and  made  correctly.  The 
treatment,  also,  was  adapted  to  the  nature  of  the  fracture. 
The  patient  was  at  home,  among  her  friends,  where  every 
wish  of  her  attending  surgeon  could  be  carried  out.  And  to 
those  acquainted  with  the  surgeon  in  attendance,  his  name 
alone  would  be  a  guarantee  that  everything  requisite  in  the 
treatment  was  attended  to,  even  had  no  mention  been  made 
of  the  dressings  in  the  case. 

Those  dressings  were  Amesbury's  splint,  with  side  splints  ; 


15 

a  form  of  dressing  insuring  perfect  rest  of  the  parts.  These 
dressings  were  kept  on  for  six  weeks  undisturbed,  then  the 
limb  was  carefully  examined,  dressings  replaced,  and  continued 
for  three  weeks  longer ;  everything,  meanwhile,  being  attend- 
ed to  which  the  surgeon  in  attendance  thought  conducive  to 
union.  Under  these  most  favorable  circumstances  for  osseous 
union,  this  result  was  not  obtained  ;  the  patient  remained  a 
cripple  for  life ;  the  process  of  absorption  of  the  fractured  end 
of  the  bone  went  on,  and  at  the  time  of  her  death  the  parts 
were  found  as  already  described.  If  this  was  the  only  case  of 
the  kind  which  could  be  adduced,  then  it  might  be  regarded 
as  a  rare  exception ;  but  cases  of  the  kind  can  be  easily  mul- 
tiplied, quite  as  conclusive  as  that  just  mentioned. 

There  is  in  the  museum  of  Prof.  William  H.  Van  Buren,  of 
the  University  Medical  College,  a  specimen  precisely  in 
point.  I  am  under  obligations  to  Prof.  Van  Buren  for  the 
history  of  the  case,  which  he  furnished  me,  and  also  for  the 
privilege  of  fully  examining  the  specimen. 

Case  2. — History. — The  patient  was  a  man,  set.  25  years  ; 
robust ;  in  good  health.  He  was  dancing  at  his  sister's  wed- 
ding ;  while  cutting  a  pidgeon  wing,  he  struck  the  foot 
upon  which  he  was  resting  from  under  him,  and  fell,  striking 
directly  upon  the  trochanter  major.  He  was  unable  to  rise ; 
a  carriage  was  called  and  he  was  taken  directly  to  the  New 
York  Hospital.  There  he  came  under  the  charge  of  Dr.  J. 
Kearney  Rodgers.  A  fracture  was  immediately  diagnosti- 
cated, and  for  a  few  days  he  was  kept  on  the  double  inclined 
plane.  The  straight  splint  was  then  used,  and  the  dressings 
kept  up  for  six  weeks,  at  the  end  of  that  time  they  were 
taken  down  and  the  limb  examined  :  there  was  no  union. 
The  limb  was  continued  in  the  straight  splints  for  three 
weeks  longer,  and  again  examined — there  was  still  no  union. 
The  patient  was  again  replaced  in  the  straight  splint  for  two 
weeks  longer,  but  no  union  occurred.  At  the  end  of  three 
months  from  his  admission,  he  was  discharged ;  he  was  in 
good  health,  but  so  lame  that  he  was  obliged  to  use  two 
crutches  in  walking.  After  his  discharge,  the  patient  became 
very  intemperate ;  and,  in  the  course  of  a  few  weeks,  he 
applied  for  admission  to  Bellevue  Hospital.  He  was  much 
debilitated,  and  had  an  exhausting  diarrhoea.  Shortly  after 
his  admission,  an  immense  abscess  formed  over  the  joint, 
which  discharged  profusely.  The  man  died  shortly  after, 
from  exhaustion,  and  the  specimen  came  into  Dr.  Van  Buren's 
hands,  the  patient  having  been  in  his  service.      Dr.  Van 


16 

Buren  was  aware  of  the  patient's  previous  history,  the  treat- 
ment, etc.,  at  the  New  York  Hospital,  and  a  careful  exam- 
ination was  made. 

Post- Mortem  Examination. — The  capsular  ligament  was 
destroyed  entirely  by  the  suppurative  process  j  there  was  a 
formation  of  callus  upon  the  trochanter  major  ;  the  ligamen- 
tum  teres  was  entirely  absorbed  ;  the  head  of  the  bone  was 
spongy,  as  if  worm  eaten  ;  the  direction  of  the  fracture  was 
oblique,  commencing  just  at  the  articulating  surface  of  the 
head  and  ending  just  within  the  capsule ;  the  upper  end  of 
the  shaft  of  the  bone  showed  this  same  appearance  that  was 
marked  in  the  head.  These  points  are  beautifully  shown  in 
the  specimen  at  the  present  time.  The  opinion  of  Charles 
E.  Isaacs,  M.D.,  the  able  Demonstrator  of  Anatomy  of  the 
University  Medical  College,  is,  that  this  fracture  was  entirely 
within  the  capsule. 

Remarks. — Here  was  a  strong,  healthy  man,  in  the  prime 
of  life,  with  no  constitutional  taint,  with  an  immediate  diag- 
nosis of  his  fracture,  and  immediate  and  proper  treatment, 
and  that  treatment  continued  for  three  months,  under  the 
supervision  of  Dr.  J.  Kearney  Eodgers,  with  all  the  advan- 
tages of  the  New  York  Hospital,  where  more  fractures  are 
treated  than  in  any  other  institution  in  this  country ;  every- 
thing being  attended  to  that  would  facilitate  union.  The 
patient's  general  health  was  carefully  attended  to  as  is 
shown  by  his  condition  at  the  time  of  his  discharge.  Not- 
withstanding all  these  advantageous  conditions,  there  was 
no  union.  If  health,  constitution,  youth,  and  good  treat- 
ment give  no  such  results,  what  are  we  to  hope  for  from 
age  and  debility? 

We  shall  now  proceed  to  analyze  the  specimens  which 
have  been  brought  forward  to  prove  the  union  of  intra-cap- 
sular  fracture  of  the  cervix  femoris.  If  there  is  a  single  speci- 
men, about  which  there  could  be  no  doubt  of  there  having  been 
a  fracture  entirely  intra-capsular,  and  of  that  fracture  unit- 
ing by  osseous  union,  that  specimen  would  settle  the  possi- 
bility of  osseous  union  in*  cases  of  intra-capsular  fractures  of 
the  cervix  femoris.  But  is  there  a  single  specimen  of  this 
kind  in  existence  ?  Eobert  W.  Smith,  of  Dublin,  in  his  ex- 
cellent work  on  Fractures,  claims  to  have  collected  facts 
which  settle  this  question.  He  has  searched  the  museums 
of  England,  Ireland,  and  France,  for  their  choice  specimens, 
and  has  been  able  to  collect  only  seven  which  have  any  pre 
tense  of  this  kind.     Prof.  Willard  Parker,  of  this  city,  has 


17 

one ;  Philadelphia  claims  to  have  two;  and  Prof.  E.  D.  Mus- 
sey,  of  Cincinnati,  has  three  specimens,  which  he  alleges 
are  perfect  illustrations  of  the  osseous  union  of  intra-capsu- 
lar  fractures  of  the  cervix  femoris. 

The  greatest  number  collected  are  in  the  work  of  Robert 
W.  Smith,  of  Dublin,  on  Fractures  ;  they  are  seven  in  number. 
The  first  of  these  cases  is  that  of  Mr.  LangstafF's,  which  is 
the  strongest  case ;  the  notes  of  this  case,  both  as  published 
in  the  Medico-Chirurgical  Transactions,  vol.  13,  page  49 1 , 
No.  242,  and  in  Mr.  Smith's  work  on  Fractures,  page  57,  are 
extremely  meagre.  Mr.  Smith's  report  is  as  follows  (page 
57) : — "  In  this  case,  the  patient  was  a  female,  aet.  50  years, 
when  the  fracture  happened.  She  was  confined  to  her  bed 
for  nearly  twelve  months  after  the  occurrence  of  the  acci- 
dent, and  during  the  remainder  of  her  life,  a  period  of  ten 
years,  wTalked  with  crutches.  On  dissection,  it  was  found 
that  the  principal  part  of  the  neck  of  the  bone  was  absorbed  ; 
the  head  and  remaining  portion  of  the  neck  were  united, 
principally  by  bone,  and  partly  by  a  cartilaginous  substance. 
On  making  a  section  of  the  bone,  it  was  evident  that  there 
had  been  a  fracture  of  the  neck  within  the  capsular  ligament, 
and  that  union  had  taken  place  by  osseous  and  cartilaginous 
media.  With  a  view  of  ascertaining  whether  there  was  real 
osseous  union,  the  bone  was  boiled  many  hours,  which,  by 
destroying  all  the  animal  matter,  satisfactorily  proved  the 
extent  and  firmness  of  the  osseous  connection,  and  exhibited 
the  spaces  which  had  been  occupied  by  cartilaginous  matter." 

No  mention  is  made  of  the  treatment  adopted  in  the  case. 
The  only  statement  that  can  in  any  way  be  considered  as 
bearing  on  this  point,  is  that  she  was  confined  to  her  bed  for 
twelve  months.  This  was  probably  because  she  could  not 
get  up,  for  if  Mr.  LangstafF  had  required  her  to  be  kept  in 
bed,  as  a  part  of  the  treatment,  he  would  doubtless  have  men- 
tioned it.  He  does  not  state  whether  any  splints  were  used, 
or  any  other  means  adopted  to  keep  the  parts  in  coaptation. 
These  are  important  particulars  ;  for  Mr.  Smith  says  (page  64) 
it  is  by  contact  and  rest,  that  we  are  to  hope  for  bony  con- 
solidation. 

Again,  all  the  proof  of  there  ever  having  been  a  fracture 
must  be  derived  from  the  statement  of  Mr.  LangstafF;  for 
there  is  not  a  single  symptom,  nor  a  single  fact  mentioned, 
to  lead  to  such  a  conclusion,  except  that  the  woman  kept 
her  bed  for  twelve  months  after  the  accident,  and  was  after- 
wards lame  for  life.     Nor  does  he  give  us  any  reason  where- 


18 

by  he  came  to  this  conclusion  from  the  autopsy.  There  are 
no  measurements  given  to  show  how  far  within  the  capsule 
the  fracture  was ;  or,  how  near  to  the  capsule  the  fracture  ap- 
proached at  its  nearest  point  of  approximation.  In  fine,  the 
capsule  itself  is  not  preserved,  or  even  the  smallest  portion 
of  it,  from  which  to  furnish  points  of  measurements.  Noth- 
ing is  given  but  the  simple  statement  of  Mr.  Langstaff,  that, 
"  On  making  a  section  of  the  bone,  it  was  evident  that  there 
had  been  a  fracture  of  the  neck  within  the  capsular  liga- 
ment, and  that  union  had  taken  place  by  osseous  and  carti- 
laginous media."  In  all  cases  of  controversy,  the  public  have 
the  right  to  know  the  reasons  upon  which  an  opinion  is 
founded,  especially  if  they  are  called  upon  to  believe  that 
opinion.  In  this  particular  case,  it  was  of  the  utmost  im- 
portance that,  instead  of  mere  assertion,  a  systematic  state- 
ment of  the  case  should  have  been  given,  with  measurements 
from  certain  fixed  points,  and  minute  descriptions  of  the 
various  abnormal  peculiarities ;  that,  from  these  measurements 
and  descriptions,  logical  conclusions  might  have  been  drawn. 
Mr.  Langstaff  makes  the  statement  that  the  head  of  the 
bone  was  united  to  the  shaft  by  bone,  and  that  the  neck  was 
absorbed.  The  same  objection  exists  to  this  which  did  to  his 
first  statement ;  he  gives  us  none  of  the  reasons  whereby 
he  came  to  the  conclusion  that  this  was  the  head  of  the  bone 
which  remained ;  he  does  not  inform  us  whether  the  liga- 
mentum  teres  was  attached  to  it  or  not ;  he  does  not  men- 
tion whether  the  vessels  of  the  ligament um  teres  were  en- 
larged or  not,  as  they  would  be  had  they  sustained  the  head 
of  the  bone,  and  also  furnished  the  osseous  union  existing. 
In  fine,  the  notes  are  so  carelessly  taken,  that  he  does  not 
mention  whether  there  was  a  ligamentum  teres  or  not.  There 
is  no  ligamentum  teres  represented  in  the  engraving ;  it  is 
presumed  that  the  engraving  is  a  fair  representation  of  the 
specimen, — for  it  is  presented  for  that  purpose  by  Mr.  Smith. 
As  nothing  is  said  of  a  ligamentum  teres,  and  none  is  shown 
in  the  plate  that  represents  the  specimen,  it  is  right  to  con- 
clude there  was  no  ligamentum  teres.  This  was  probably  a 
case  of  the  absorption  of  the  head  of  the  bone,  from  the 
results  of  the  injury.  This  is  rendered  probable  from  analogy 
and  from  the  facts  in  the  case.  Illustrations  of  this  absorp- 
tion of  the  head  of  the  bone  are  abundant ;  we  find  them  in 
this  same  article  of  Mr.  Smith's,  page  71,  Case  6.  (Esther 
Christie.)  In  that  case  we  are  told  :  "  The  upper  fragment 
has  been  absorbed  as  far  as  the  acetabulum,  and  the  ligamen- 
tum teres  was  the  sole  remaining  attachment  of  the  bone." 


19 

Here  the  process  of  absorption  of  the  fractured  head  of  the 
bone  is  going  on,  the  head  of  the  bone  is  absorbed  as  far  as 
the  acetabulum,  while  the  surface  of  the  lower  fragment  is 
becoming  "covered  with  a  fibrous  deposit,  though  still  rough," 
to  enable  it  to  fulfill  its  new  function.  Case  7,  page  72 
(Mary  Lamb),  gives  the  same  process  of  absorption  going  on. 
In  this  case,  the  patient  died  twelve  months  after  the  injury, 
yet  the  head  of  the  bone  is  absorbed  as  far  as  the  acetabulum, 
and  fibrous  structure  formed,  all  of  which  had  been  accom- 
plished in  the  space  of  twelve  months.  If,  in  this  old  woman, 
eighty  years  of  age,  absorption  had  gone  on  as  rapidly  as  here 
stated,  is  it  improbable  that  the  whole  head  of  the  bone 
should  have  been  absorbed  in  the  case  of  Mr.  LangstafT,  when 
the  patient  lived,  not  merely  twelve  months  after  the  injury, 
but  nearly  eleven  years,  and  was  only  fifty  years  of  age  in- 
stead of  eighty  ?  If  further  illustrations  of  this  absorption 
of  the  head  of  the  bone  were  desired  they  could  easily  be 
multiplied.  The  case  of  Dr.  Wm.  H.  Van  Buren's  is  in  point ; 
in  that  the  ligamentum  teres  was  absorbed  besides  the  pro- 
cess in  the  head  of  the  bone.  The  case  of  the  girl  M.  J., 
under  Dr.  Wood's  charge,  is  another  case  in  point.  There 
is  still  another  specimen  in  the  museum  of  Dr.  James  R. 
Wood,  that  illustrates  this  point ;  it  was  taken  from  a  woman 
fifty-four  years  of  age  ;  all  the  usual  signs  of  fracture  were 
fully  made  out ;  the  limb  was  immediately  placed  on  a  double 
inclined  plane,  and  retained  so  for  nearly  two  months;  the 
woman  had  no  control  over  the  motions  of  the  limb,  she  was 
unable  to  walk  without  a  crutch,  and  when  she  died,  two 
years  after  the  occurrence  of  the  injury,  the  specimen  came 
into  Dr.  Wood's  possession.  At  his  clinical  lecture  at  Bellevue 
Hospital,  Saturday,  January  3,  Dr.  Wood  exhibited  the  speci- 
men to  the  students.  The  patient,  he  stated,  died  of  pneu- 
monia two  years  after  the  injury.  The  autopsy  exhibited  the 
fracture  entirely  within  the  capsule ;  on  cutting  into  the  thick- 
ened capsule,  the  head  of  the  bone  was  found  lying  loose  in  the 
cavity ;  the  ligamentum  teres  was  entirely  absorbed  ;  the  head 
of  the  bone  had  become  exceedingly  light  and  soft,  easily 
broken  up  with  the  handle  of  a  scalpel,  the  neck  of  the  bone 
was  becoming  rounded  off  to  fulfill  its  new  function,  and  the 
neck  was  becoming  covered  with  fibrous  matter.  These 
cases  demonstrate  conclusively  the  fact  that,  in  fractures  of 
the  cervix  femoris  within  the  capsule,  the  head  is  often  under- 
going the  process  of  absorption,  and  it  is  not  unreasonable  to 
conclude  that,  in  this  patient  of  Mr.  Langstaff,  where  she 


20 

lived  for  so  long  a  time  after  the  injury,  this  process  was  com- 
pleted. 

In  the  case  of  Mr.  Langstaff's,  the  patient  was  confined  to 
her  bed  for  twelve  months,  and  lived  ten  years,  during  which 
she  was  lame  ;  if  the  head  of  the  bone  remained,  as  is  claim- 
ed, and  the  union  was  by  bone,  if  the  ligamentum  teres  re- 
mained, as  it  must  have  done  to  have  produced  this  bony 
union,  then  the  patient  should  have  had  the  use  of  the  limb ; 
but,  on  the  contrary,  she  was  lame  for  life — so  lame  that  she 
had  to  walk  with  crutches,  though  she  lived  for  a  period  of 
nearly  eleven  years  after  the  injury ;  a  circumstance  easily 
understood,  if  this  process  of  absorption  of  the  head  of  the 
bone  was  going  on  during  this  time. 

The  next  case  adduced  by  Mr.  Smith  to  support  this  view. 
is  that  of  Dr.  Brulatour,  page  58  of  Mr.  Smith's  work ;  also, 
vol.  13,  page  512,  Med.  Cfflrurg.  Transactions. 

Dr.  James,  an  English  physician,  residing  at  Bordeaux,  ast. 
47  years,  was  thrown  from  his  horse,  on  March  29,  1826. 
He  fell  directly  on  the  great  trochanter,  but  got  up  and 
walked  a  step  or  two,  which  occasioned  such  acute  pain  in 
the  hip  joint  that  he  instantly  fell  again;  on  examination 
immediately  after  the  accident,  Dr.  Brulatour  observed  the 
principal  signs  of  fracture  of  the  neck  of  the  femur,  such  as 
shortening  of  the  affected  limb,  eversion  of  the  foot,  and  a 
feeling  of  crepitation  in  the  joint  when  counter  extension  was 
made ;  extension  of  the  limb  was  kept  up  for  two  months, 
so  as  to  preserve  it  of  its  natural  length.  Three  months  after 
the  receipt  of  the  injury,  Dr.  James  was  able  to  walk  with 
only  the  assistance  of  a  cane,  and  subsequently  recovered  the 
full  use  of  the  limb.  On  the  20th  of  December,  nine  months 
after  the  accident,  he  was  attacked  with  hgematemesis,  which 
proved  fatal  in  two  days.  The  post-mortem  examination  of 
the  right  hip  joint  showed  the  capsule  a  little  thickened ;  the 
cotyloid  cavity  and  inter-articular  ligament  in  a  natural  state; 
the  neck  of  the  femur  shortened  ;  an  irregular  line  surround- 
ing the  neck,  denoting  the  direction  of  the  fracture,  and  con- 
siderable bony  deposit  at  the  bottom  of  the  head  of  the 
femur,  and  at  the  external  and  posterior  part.  A  section  of 
the  head  of  the  femur  was  made,  in  a  line  drawn  from  its 
center  to  the  bottom  of  the  great  trochanter,  so  as  perfectly 
to  expose  the  callus.  The  line  of  union,  indicated  by  the 
callus,  was  smooth  and  polished  as  ivory ;  the  line  of  callus 
denoted  also,  that  the  bottom  of  the  head  of  the  femur  had 
been  broken  off  at  its  superior  and  posterior  part. 


21 

If  these  notes  prove  anything,  they  prove  too  much ;  for 
it  is  stated  that  "  an  irregular  line  surrounding  the  neck,  de- 
noting the  direction  of  the  fracture,  and  considerable  bony 
deposit  at  its  external  and  posterior  part."  "  The  line  of 
callus,  denoted,  also,  that  the  bottom  of  the  head  of  the 
femur  had  been  broken  at  its  superior  and  posterior  part.'1 
If  this  statement  is  true,  what  must  have  been  the  nature  of 
the  injury  ?  Evidently  a  comminuted  fracture  entirely 
within  the  capsule ;  for,  the  first  line  denoted  that  the  head 
of  the  bone  had  been  fractured  off  from  the  shaft  of  the 
bone,  a  second  line  indicated  that  the  bottom  and  pos- 
terior part  of  the  head  had  been  fractured  off  from  the 
remainder.  If  the  periosteum  was  injured,  and  I  can  not 
imagine  it  to  be  otherwise,  how  would  it  be  possible  that 
this  third  portion  of  the  bone  should  be  nourished?  If 
the  head  was  nourished  by  the  ligamentum  teres,  and 
the  portion  connected  with  the  shaft  by  the  nutrient 
artery  of  the  femur,  how  would  this  third  piece  be  sus- 
tained? Yet  it  had  been  nourished,  and  was  united  to  the 
remainder  "by  callus  as  smooth  and  polished  as  ivory."  An- 
other point :  the  report  states  that  "  the  ligamentum  teres 
was  in  a  natural  state,"  and  we  are  informed  that  the  head 
of  the  bone  was  fractured  off  in  such  a  way,  that  the  larger 
part  of  it  could  only  be  nourished  by  the  ligamentum  teres. 
The  ligamentum  teres  had  in  addition  to  its  usual  functions 
nourished  this,  and  had  assisted  in  the  formation  of  the  ex- 
isting callus.  When  an  artery  performs  an  additional  func- 
tion, that  artery  becomes  enlarged.  This  is  constantly  seen 
in  the  anastomotic  circulation  of  a  ligated  vessel — the  inoscu- 
lating branches  soon  enlarge  to  the  size  almost  of  the  original 
vessels,  whose  place  they  have  supplied.  In  this  case  the 
vessels  of  the  ligamentum  teres  had  to  perform  their  own 
functions,  and  in  addition  to  nourish  this  fractured  head,  and 
assist  in  the  formation  of  callus,  yet  they  were  found  in  a 
natural  state.  We  may  add  that  Mr.  Smith  is  in  error  in 
stating  that  "  It  is  highly  probable  that  they  have  all  been 
examples  of  impacted  fractures ;"  "the  displacement  of  frag- 
ments has  been  prevented ;"  for  in  this  case  the  limb  was  at 
first  shortened,  and  then  by  dressings  drawn  down  to  its  natu- 
ral length. 

The  third  case  is  that  of  Mr.  Stanley,  of  which  the  notes 
are  as  follows : — A  young  man,  aet.  IS  years,  fell  from  the  top 
of  a  loaded  cart  upon  his  right  hip,  the  injury  of  which  was 
attended  with  the  following  symptoms : — he  was  wholly  una- 


22 

ble  to  move  the  limb ;  the  thigh  was  bent  to  a  right  angle 
with  the  pelvis,  and  could  not  be  extended;  abduction  was 
difficult ;  the  limb  was  everted ;  but  there  was  no  shorten- 
ing, nor  could  crepitus  be  felt  in  any  motion  of  the  limb. 
The  patient  died  of  what  was  supposed  to  be  small  pox, 
about  three  months  after  the  occurrence  of  the  accident.  In 
the  examination  of  the  joint  after  death,  the  capsule  was 
found  thickened,  the  round  ligament  uninjured;  a  line  of 
fracture  extended  obliquely  through  the  neck  of  the  femur, 
and  entirely  within  the  capsule ;  the  neck  of  the  bone  was 
shortened,  and  its  head  approximated  to  the  trochanter  major. 
The  fractured  surfaces  were  in  the  closest  appositon,  and 
firmly  united  nearly  in  their  whole  extent  by  bone  ;  there 
was  an  irregular  deposition  of  bone  upon  the  neck  of  the 
femur,  beneath  its  synovial  and  periosteal  covering,  along 
the  line  of  the  fracture.  At  the  end  of  his  report,  page  59, 
Mr.  Smith  refers  to  the  Medico-  Chirurgical  Transactions,  vol. 
18.  On  reference  to  this  volume,  we  find  the  following  impor- 
tant facts  which  Mr.  Smith  has  omitted  in  his  extract : — "  The 
age  of  the  patient  was  unfavorable  to  the  occurrence  of  a  frac- 
ture at  the  neck  of  the  thigh  bone.  The  general  opinion,  there- 
fore, of  the  several  surgeons  to  whose  judgment  the  case 
was  submitted,  favored  a  belief  of  a  dislocation  into  the  fora- 
men ovale.  Forcible  extension  of  the  limb  was  made  by  pul- 
leys, and  the  thigh  then  moved  in  several  directions  by  which 
the  head  of  the  bone  might  be  replaced  in  its  socket."  These 
facts  which  Mr.  Smith  has  omitted,  bear  directly  against  the 
position  he  has  assumed.  For  immediately  after  giving  the 
seven  cases,  of  which  this  is  one,  he  says  (page  64)  "  The 
preceding  cases  furnish  ample  evidence  of  the  possibility  of 
osseous  union  in  cases  of  intra-capsular  fracture  of  the  neck 
of  the  femur,  and  it  is  highly  probable  that  they  have  all 
been  examples  of  impacted  fractures.  Certainly,  in  all  those 
of  which  delineations  have  been  given,  there  has  been  either 
penetration  of  one  fragment  by  a  portion  of  the  other,  or 
else  the  irregularity  of  the  line  of  fracture  has  been  such, 
that  the  displacement  of  the  fragments  has  been  prevented. 
They  have  been  maintained  in  contact  and  at  rest,  and  it  is 
under  such  circumstances  alone,  that  we  are  to  hope  for  the 
occurrence  of  bony  consolidation."  These  are  singular  com- 
ments upon  a  case  in  which  the  limb  was  forcibly  extended 
by  pulleys,  and  then  rocked.  If  this  was  a  case  of  impacted 
fracture,  how  long  would  it  remain  so,  after  forcible  exten- 
sion by  pulleys  and  rocking  ?     Yet,  according  to  Mr.  Smith, 


23 

it  must  have  remained  an  impacted  fracture ;  for  under  those 
circumstances  alone,  does  he  believe  we  are  to  hope  for  bony 
union. 

To  an  intelligent  surgeon,  it  will  be  a  sufficient  refutation 
of  Mr.  Smith's  assumptions,  by  simply  stating  the  following 
facts.  The  case  was  at  first  treated  for  a  dislocation,  and  not 
till  the  second  month  was  the  patient  brought  to  the  hospi- 
tal. Shortly  after  his  admission,  he  was  attacked  with  an 
exanthem  of  which  he  died.  Is  it  probable  that  a  fracture 
within  the  capsule  of  the  cervix  femoris,  mistaken  for  dislo- 
cation, would  have  that  perfect  contact  and  rest  (a  sine  qua 
non  of  ossificunion  with  Mr.  Smith),  without  which  we  can 
not  hope  for  bony  consolidation,  when  the  limb  is  first 
forcibly  extended  by  pulleys  and  rocked,  then  the  patient  is 
removed  to  a  hospital,  where  he  soon  after  dies  from  an  attack 
of  acute  disease,  and  all  this  occurring  within  the  space  of 
three  months,  from  the  injury  ? 

Case  4 — (Mr.  Swan's  case). — Mr.  Smith's  notes  are  as  fol- 
lows : — "  Mrs.  Powel,  above  SO  years  of  age,  fell  down,  No- 
vember 14,  1824.  Sir  Astley  Cooper,  who  saw  her  soon 
after,  believed  that  there  was  a  fracture  of  the  neck  of  the 
femur,  although  there  was  no  appreciable  shortening  of  the 
limb,  and  only  a  slight  inclination  of  the  toes  outward ;  crepi- 
tus could  not  be  perceived ;  the  patient  died  about  five  weeks 
after  the  accident ;  upon  examination  of  the  joint  after  death, 
the  fracture  was  found  to  have  been  entirely  within  the  cap- 
sular ligament,  and  the  greater  part  of  it  was  firmly  united. 
A  section  was  made  through  the  fractured  part,  and  a  faint 
white  line  was  seen  in  one  portion  of  the  union,  but  the  rest 
appeared  entirely  of  bone.  The  cervical  ligament  had  not 
been  injured."  (Smith,  page  59.)  In  this  case,  the  patient 
was  an  old  lady,  above  SO  years  of  age,  with  the  fracture 
not  certainly  made  out ;  there  was  no  appreciable  shortening 
of  the  limb  ;  no  crepitus ;  and  only  a  slight  inclination  of  the 
toes  outward.  The  strongest  point  in  favor  of  there  having 
been  a  fracture,  was  the  opinion  of  Sir  Astley  Cooper,  which 
opinion  is  entitled  to  great  weight ;  but  there  are  no  sat- 
isfactory facts  given  upon  which  he  formed  that  opinion. 
This  slight  eversion  of  the  foot  might  be  given  by  the  patient 
to  relieve  the  tension  on  the  bruised  and  inflamed  part.  We 
may  well  queiy  if  the  vessels  of  the  ligamentum  teres  would 
not  have  shown  evidences  of  having  performed  an  increased 
function  ?  Would  five  weeks  have  been  sufficient  time  for 
them  to  furnish  osseous  union,  and  resume  their  original  size  ? 


24 

Again,  the  old  woman  died  in  five  weeks  after  the  receipt 
of  the  injury.  Now,  it  seems  to  us  quite  improbable,  nay, 
impossible,  that  bony  union  of  an  intra-capsular  fracture  of  the 
femur  in  an  old  woman,  above  eighty  years  of  age,  in  whom 
there  was  not  left  vitality  enough  to  sustain  life,  should  take  place 
in  five  weeks  after  the  injury — in  less  time  than  is  allowed  for 
the  ordinary  union  of  a  fracture  of  the  shaft  of  the  femur  in  a 
healthy  person  in  the  prime  of  life. 

Case  5 — (Mr.  Adams'  case). — This  case  is  reported  more 
fully  and  is  accompanied  with  an  engraving,  illustrating  it, 
page  61.  The  engraving  must  be  considered  correct — for  it  is 
fair  to  presume  that  it  would  not  be  made  to  represent  the 
case  any  more  unfavorable  to  the  side  of  the  question  Mr. 
Smith  argues  than  the  facts  in  the  case  required.  Now,  this 
engraving  shows  the  line  of  union  to  extend  nearly  to  the  base 
of  the  trochanter  minor,  a  point  far  without  the  capsule. 
(See  second  engraving,  on  page  61,  Smith  on  Fractures.) 
This  makes  it  a  case  of  fracture  partly  within  and  partly 
without  the  capsule — a  class  of  fractures  which  every  one 
admits  may  readily  unite  by  bone. 

Case  6 — (Mr.  Jones'  case). — Of  this  case  Mr.  Smith  makes 
the  remark,  page  63  :  "  this  specimen  was  sent  to  Sir  Astley 
Cooper  for  examination  ;  Sir  Astley  was  of  opinion,  that  the 
fracture  was  '  in  part  within,  and  in  part  external  to,  the  cap- 
sular ligament ;  in  part  united,  and  in  part  not ;  and  the  neck 
of  the  thigh  bone  absorbed.' "  This  excludes  it  from  the  class 
of  intra-capsular  fractures. 

Case  7 — (Mr.  Chonly's  case). — Mr.  Smith  says  of  this  case, 
"  A  portion  of  the  upper  fragment  extended  in  one  situation,  a 
little  external  to  the  capsule,  this  portion  was  not  united." 
Mr.  Smith  adduces  this  to  prove  that  intra-capsular  fractures 
unite,  and  yet  admits  it  does  not  belong  to  the  class,  and  is 
not  an  intra-capsular  fracture. 

This  completes  the  specimens  adduced  by  Mr.  Smith,  to 
prove  this  ossific  union  of  intra-capsular  fractures  of  the 
cervix  femoris.  It  will  be  remembered  these  are  not  the  speci- 
mens of  one  country  alone,  but  the  choice  specimens  culled 
from  the  museums  of  all  Europe.  In  this  country,  the  largest 
number  of  specimens  are  in  the  possession  of  Prof.  Mussey,  of 
Cincinnati.  He  claims  to  have  three  specimens  which  prove 
this. 

Of  these  three,  the  most  valuable  one  is  that  about  which 
Prof.  Mussey  and  Dr.  Dalton,  of  Lowell,  Mass.,  maintained 
so  long  a  controversy.    The  circumstances  of  the  case,  as  far 


25 

as  we  have  been  able  to  gather  them  from  Prof.  Farker's  lec- 
ture, and  from  the  statements  of  Dr.  Morrell,  of  Borodino, 
N.  Y.,  who  was  one  of  Prof.  Mussey's  students  shortly  after 
the  controversy,  are  as  follows  : — The  patient  was  a  team- 
ster, away  from  his  home  in  Northern  New  Hampshire  when 
he  met  with  the  accident;  Dr.  Dalton  became  satisfied  there 
was  a  fracture,  and  treated  him  for  it.  The  man  became  dis- 
satisfied. Dr.  Dalton  boxed  up  the  leg  and  sent  the  man  home, 
a  distance  of  more  than  one  hundred  miles,  in  one  of  the  or- 
dinary country  wagons,  over  the  rough  roads  of  that  hilly 
country ;  on  his  arrival  home,  the  man's  limb  was  examined 
by  Prof.  Mussey,  about  three  weeks  after  the  injury,  the 
dressings  removed,  yet  no  fracture  could  be  found ;  Prof.  Mus- 
sey maintained  this  opinion  till  he  came  in  possession  of  the 
specimen,  which  he  thought  showed  conclusively  there  was 
a  fracture  within  the  capsule,  and  which  had  united  by  bone, 
when  he  made  the  amende  honorable.  If  we  had  only  these 
facts  to  rely  upon,  they  would  be  sufficient  to  throw  a  doubt 
on  the  nature  of  the  injury.  No  matter  how  skillful  the 
surgeon  might  have  been,  or  how  favorable  the  circumstances 
surrounding  the  patient,  it  would  have  been  impossible  to 
have  obtained  an  union  of  a  fracture  entirely  within  the  cap- 
sule in  four  weeks'  time.  Dr.  Dalton  may  have  boxed  up 
the  limb  in  the  most  skillful  manner,  and  he  is  a  surgeon  of 
high  repute  in  Eastern  Massachusetts,  yet,  it  would  have  been 
impossible  to  have  applied  his  pressure  so  equally  as  to  keep 
the  head  of  the  femur  still — jolted,  as  the  man  must  have 
been,  in  one  of  those  old-fashioned,  springless  wagons,  over 
the  half-built  mountainous  roads  of  Northern  New  Hamp- 
shire, for  a  distance  of  a  hundred  miles — and  yet  have,  at  the 
end  of  that  journey,  an  union  of  an  intra-capsular  fracture,  so 
perfect  that  Prof.  Mussey  denied  there  ever  had  been  a  frac- 
ture there. 

But  these  are  not  the  only  facts  in  the  case ;  Dr.  Black- 
man  (editor  of  Velpeau's  Operative  Surgery,)  has  given  us 
the  true  explanation  of  the  case.  In  his  review  of  Malgaine 
on  Fractures,  while  discussing  this  question  of  intra-capsular 
fractures,  states  (New  York  Journal  of  Medicine,  Sept.,  1S55,) 
that  Prof.  Mussey  took  this  specimen  to4  Sir  Astley  Cooper,  to 
convince  him  of  the  possibility  of  bony  union  of  intra-cap- 
sular fractures ;  but  Sir  Astley  decided  this  to  be  a  case  of 
fracture,  partly  within  and  partly  without  the  capsule. 

Of  Prof.  Mussey's  two  remaining  specimens  I  have  been 
unable  to  procure  histories.   I  have  conversed  with  a  surgeon 


26 

of  eminence  of  this  city,  who  has  examined  them  carefully, 
and  he  says  they  are  no  more  satisfactory  than  the  one  already 
referred  to.  Dr.  Bauer,  of  Brooklyn,  has  also  recently  examin- 
ed them,  and  is  very  strongly  of  the  opinion  that  they  are  not 
specimens  of  intra-capsular  fracture. 

Since  the  above  was  written,  we  have  received  the  Ameri- 
can Journal  of  Medical  Sciences,  for  April,  1857.  The  lead- 
ing article  is  by  Prof.  Mussey,  detailing  his  cases  of  "  Frac- 
ture of  the  Neck  of  the  Thigh  Bone." 

We  are  gratified  to  find  the  facts  of  Case  1,  as  above  stated, 
corroborated  by  Prof.  Mussey  in  all  essential  particulars.  In 
this  article,  Prof.  Mussey  admits  his  inability  to  convince  Sir 
Astley.     He  details  his  interview  as  follows  : — 

"  On  my  presenting  it  for  inspection  to  Sir  Astley  Cooper, 
he  remarked,  '  this  bone  never  was  broken,'  I  said,  '  Sir 
Astley,  please  to  look  at  the  interior  of  the  bone  ;'  he  sepa- 
rated the  two  halves  and  said,  '  this  does  look  a  little  more 
like  it  to  be  sure,  but  I  do  not  think  it  is  wholly  within  the 
capsular  ligament.'  It  is  well  known  that  Sir  Astley  Cooper, 
for  some  years,  had  taught  the  doctrine  that  bony  union  does 
not  take  place  in  intra-capsular  fracture ;  his  views,  among 
the  surgeons  of  Great  Britain,  were  extensively  admitted  as 
correct." 

This  last  remark,  following,  as  it  does,  his  account  of  his 
interview  with  Sir  Astley^would  appear  to  be  Prof.  Mussey's 
assigned  reason  for  his  own  success. 

It  is  possible  that  Sir  Astley  Cooper  was  so  prejudiced  as 
not  to  admit  as  facts,  points  that,  at  best,  were  but  doubtful, 
but  it  will  hardly  be  presumed  that  Sir  Astley  Cooper  would 
deny  facts  about  which  there  could,  be  no  reasonable  doubt.  This 
is  not  the  only  occasion  in  which  Sir  Astley's  motives  have 
been  impugned.  A  distinguished  lecturer  of  this  country 
has,  in  his  public  teachings,  declared  that  Sir  Astley  Cooper, 
by  teaching  this  doctrine  of  the  non-union,  "  had  done  more 
harm  than  he  had  ever  done  good  in  his  life,"  but  those  who 
have  studied  Sir  Astley's  works,  with  an  unprejudiced  mind, 
would  prefer  to  believe  that  he  lived  alone  for  truth,  for 
science,  and  his  profession. 

Sir  Astley  Cooper,  is  not  the  only  surgeon  of  distinction 
whom  this  specimen  has  not  convinced.  Prof.  Mussey  men- 
tions John  Thompson,  of  Edinburgh,  a  surgeon  of  eminence 
as  well  as  an  author  of  a  work  upon  inflammation,  as  one  who 
was  not  convinced  by  this  specimen. 

As  to  Prof.  Mussey's  sweeping  statement : — "  The  profes- 


27 

sional  gentlemen  of  our  country,  who  have  examined  these 
specimens,  unhesitatingly  pronounce  this  to  be  a  case  of  union 
by  bone  of  intra-capsular  fracture,"  if  he  will  take  the  trouble 
to  ascertain  the  opinion  of  many  of  the  New  York  surgeons, 
who  have  examined  this  specimen,  he  will  find  that  this  as- 
sertion will  admit  of  essential  modifications. 

Prof.  Mussey  details  several  other  cases  in  his  own  and  in 
other's  practice — but  this  is  his  best  specimen.  He  also  makes 
some  valuable  suggestions  as  to  the  manner  of  union  and  his 
method  of  measurement.  And  we  refer,  with  pleasure,  those 
interested  to  the  American  Journal  of  Medical  Sciences,  for 
April,  1857,  for  a  further  elucidation  of  his  views. 

In  regard  to,  the  Philadelphia  specimens,  my  only  source  of 
information  is  the  brief  notice  of  them  in  the  new  work  on 
Surgery,  by  Prof.  H.  H.  Smith,  of  Philadelphia.  His  state- 
ment is  as  follows  (page  399) : — "There  is  in  the  Wistar  and 
Horner  Museum  of  the  University  of  Pennsylvania,  a  femur, 
apparently  of  an  old  woman,  in  which  the  neck  has  been  frac- 
tured near  the  head,  yet,  in  which  complete  osseous  union, 
though  with  some  degree  of  shortening,  has  taken  place.  I 
have,  moreover,  in  my  own  cabinet  a  specimen  in  which  the 
bone  has  been  fractured  through  the  neck  near  the  head,  the 
fragment  having  slid  down  beneath  its  natural  position,  and 
the  fracture  traveled  obliquely  down  the  neck,  though  still 
within  the  capsule,  splitting  it  off  in  the  line  of  the  inter- 
trochanteric ridge.  In  this  case,  which  must  have  produced 
marked  shortening  of  the  limb,  there  is  complete  osseous 
union."  This  report  is  so  exceedingly  brief  that  no  in- 
ference can  be  drawn  from  it,  in  fact,  the  writer  does  not 
appear  to  know  whether  the  specimen  is  from  a  male  or  fe- 
male. If  this  is  true,  then  he  knows  nothing  of  the  history 
of  it.  He  does  not  give  us  the  direction  of  the  fracture,  or 
a  drawing  of  it,  or  even  a  positive  statement  that  it  is  en- 
tirely within  the  capsule.  In  regard  to  his  own  specimen, 
he  is  more  explicit ;  he  gives  a  drawing  and  shows  that  the 
fractured  head  has  slipped  down,  and  even  now  the  line  of 
fracture  can  be  traced  to  the  inter-trochanteric  line.  If  this 
is  so  now,  it  is  probable  that  the  end  of  the  fractured  bone 
extended  below  the  capsule  in  the  first  place,  as  in  all  cases  of 
fracture,  where  there  is  not  perfect  coaptation,  the  rough  points 
become  absorbed.  If  we  allow  for  this  absorption,  it  would 
make  the  end  of  the  bone  below  the  trochanteric  line,  a  point 
without  the  capsule,  thus  excluding  it  from  this  class.  If  we 
adopt  Prof.  Smith's  view,  that  this  was  entirely  within,  we 


28 

meet  with  an  objection  ;  he  states  that  the  head  of  the  bone 
has  slipped  down  beneath  its  natural  position,  and  the  frac- 
ture has  traversed  it  obliquely.  This,  of  course,  could  not 
have  been  an  impacted  fracture,  for  in  an  impacted  fracture 
we  should  have  had  the  shaft  of  the  bone  driven  into  the 
cancellated  portion  of  the  head — not  the  head  of  the  bone 
"  slipping  down"  along  the  shaft.  If  this  was  a  case  of  slip- 
ping down  of  the  head,  we  leave  Prof.  Smith,  of  Philadelphia, 
to  controvert  the  position  taken  by  Mr.  Smith,  of  Dublin, 
where  he  says  that  only  impacted  intra-capsular  fractures  can 
have  an  osseous  union. 

There  remains  but  one  more  specimen  to  examine.  This 
belongs  to  Prof.  Willard  Parker,  of  this  city.  I  am  under 
obligations  to  Prof.  Parker,  for  his  kindness  in  explaining  to 
me  the  various  points  which  he  considers  the  case  presents. 
He  loaned  me  the  specimen  to  examine  at  my  leisure,  that 
I  might  become  thoroughly  acquainted  with  all  the  facts  of 
the  case.  According  to  the  description  of  the  case  given  by 
Prof.  Parker,  in  his  lecture,  the  patient  was  an  old  maid,  of 
about  sixty  years  of  age,  an  inmate  of  the  almshouse,  of  Bar- 
nard, Vt.  One  morning,  while  going  out  of  doors,  she  fell 
striking  upon  her  hip.  The  doctor  in  attendance,  who  did 
not  pretend  to  be  a  surgeon,  or  accurate  in  his  diagnosis, 
came  to  the  conclusion  that  there  was  a  fracture.  He  was 
of  the  opinion  that  he  obtained  crepitus,  accordingly  he 
dressed  the  limb  with  the  straight  splint  for  six  weeks,  and 
at  the  end  of  that  time  found  half  an  inch  shortening.  The 
specimen  afterwards  came  into  Prof.  Parker's  possession.  The 
points  Prof.  Parker  relies  on  to  show  that  this  was  a  fracture, 
are : — 1.  The  supposed  crepitus.  2.  A  ridge  of  bone  along 
the  inter-trochanteric  line,  termed  the  "  callus."  3.  The 
neck  of  the  bone  shortened  on  the  outer  side  one-third  of  an 
inch  more  than  on  the  inner  side,  this  being  accounted  for 
on  the  supposition  that  it  was  produced  by  the  position  the 
limb  was  allowed  to  retain.  4.  No  such  changes  are  to  be 
found  in  the  femur  of  the  opposite  side,  which  is  pronounced 
healthy.  These  specimens  were  procured  four  years  after 
the  injury.  The  capsule  is  entirely  gone,  and  there  is  noth- 
ing to  show  positively  where  it  was  inserted ;  a  line  is  pointed 
out  about  three  lines  below  the  so-called  callus,  as  the  line 
of  insertion  of  the  capsule.  On  examination  of  the  interior 
of  the  specimen,  there  is  nothing  to  indicate  the  line  of  frac- 
ture ;  no  callus  as  is  shown  on  internal  examination  of  other 
fractures  of  long  bones.     There  is  one  point  very  marked  on 


29 

the  inner  edge  of  the  compact  structure  of  the  shaft,  it  is 
what  Sir  Astley  Cooper  terms  a  "  buttress  of  bone  "  shoot- 
ing up  from  the  body  into  the  neck  and  head,  evidently  as  a 
support  to  the  head  in  the  new  angle  which  it  has  assumed, 
with  respect  to  the  shaft.  This  buttress  is  formed  appa- 
rently by  the  cancellated  structure  being  more  compact  than 
in  other  points.  On  comparing  this  specimen  with  the  femur 
of  the  well  limb,  a  very  marked  difference  is  observable : 
this  line  or  buttress  is  stronger,  better  developed,  and  is  evi- 
dently for  the  purpose  of  giving  support  to  the  head  of  the 
bone  in  this  new  position.  The  specimen  is  far  from  being 
satisfactory.  If  this  rough  line  extending  along  the  inter- 
trochanteric line,  is  in  reality  the  line  of  callus,  then  it  is  ex- 
tremely probable  that  the  fracture  was  partially  extra-capsu" 
lar.  For  if  the  capsule  extended  along  the  line  which  runs 
below  this  line  that  is  pointed  out  as  the  line  of  fracture,  then 
the  insertion  of  the  capsule  must  have  been  as  low  down  as 
the  middle  of  the  trochanter  minor,  an  anomaly  in  regard 
to  insertion  of  the  capsule.  If  this  really  was  the  line  of 
insertion,  it  is  extremely  unfortunate  that  the  capsule  was 
not  left  to  show  really  where  it  was  inserted. 

Again,  there  is  no  callus  on  the  inside  of  the  bone  corre- 
sponding to  this  so-called  external  callus,  but  throughout 
the  whole  line  corresponding  to  this  external  "  callus,"  the 
cancellated  structure  is  perfect.  If  it  should  be  admitted  that 
crepitus  was  here  obtained,  a  point  which  is  extremely  doubt- 
ful, as  we  have  only  the  opinion  of  a  doctor  who  practiced 
many  years  ago  in  the  small  town  of  Barnard,  Vt.,  a  town 
which  now  numbers  less  than  two  thousand  inhabitants,— if  it 
should  be  admitted  on  such  authority  that  this  was  a  frac- 
ture, still  it  is  by  no  means  established  that  this  was  an  intra- 
capsular fracture  ;  for  this  so-called  callus  extends  along  the 
inter-trochanteric  line.  The  capsule  itself  is  gone,  so  that 
it  can  not  be  shown  positively  where  it  was  inserted,  and  it 
is  probable  if  there  was  a  fracture,  it  was  partly  extra-cap- 
sular. 

Again,  the  view  which  Prof.  Parker  takes  of  his  specimen 
conflicts  with  that  taken  by  Robert  W.  Smith,  of  Dublin,  on 
fractures  of  this  class,  in  his  work  already  quoted.  For  if 
there  was  crepitus,  then  there  must  have  been  motion  of  one 
fragment  or  the  other ;  and  if  there  was  motion,  then  the 
fracture  was  not  impacted ;  and  it  is  only  this  latter  class 
which  Mr.  Smith  contends  can  unite.  My  own  impression 
is  that  there  never  was  a  fracture  here  at  all.     I  think  this 


30 

is  a  case  of  interstitial  absorption  of  the  neck  of  the  bone  ; 
the  cause  of  this  absorption  being  the  contusion  received  by 
the  fall.  This  view  is  sustained  by  analogy.  Sir  Astley 
Cooper  says  this  is  common  in  old  people ;  in  his  work  on 
Surgery,  vol.  2,  pages  314  and  315,  Lee's  edition,  we 
find  the  following  : — -"As  the  shell  becomes  thin,  ossific 
matter  is  deposited  on  the  upper  side  of  the  cervix,  opposite 
the  edge  of  the  acetabulum,  and  often  a  similar  portion  at 
its  lower  part,  and  thus  the  strength  of  the  bone  is  in  some 
degree  preserved.  This  state  of  things  may  be  frequently 
seen  in  very  old  persons."  "  When  the  absorption  of  the 
neck  proceeds  faster  than  the  deposit  on  the  surface,  the 
bone  breaks  from  the  slightest  cause;  and  this  deposit  wears 
so  much  the  appearance  of  an  united  fracture,  that  it  might 
be  easily  mistaken  for  it  before  the  bone  thus  alters.  We 
sometimes  meet  with  a  remarkable  buttress  shooting  up  from 
the  shaft  of  the  bone  into  its  head,  giving  it  additional  sup- 
port to  that  which  it  receives  from  the  deposit  of  bone  on 
its  external  surface." 

Mr.  Liston,  in  his  Practical  Surgery,  says : — "  Gradual 
shortening  of  the  lower  extremity  often  ensues  upon  contusions 
of  the  hip  in  persons  advanced  in  life,  in  consequence  of  in- 
terstitial absorption  of  the  neck  of  the  thigh  bone,  and  altera- 
tion of  the  angle  in  which  it  is  set  upon  the  shaft.  The  head 
of  the  bone  undergoes  a  change  in  form  ;  it  becomes  flat- 
tened and  expanded,  and  the  cotyloid  cavity  is  made  to 
correspond.  This  cause  of  lameness  ought  to  be  kept  in 
view.  The  risk  of  its  occurrence  ought  to  be  explained  to 
those  who  have  suffered  injury  of  the  hip,  and,  if  possible,  it 
must  be  prevented. 

Mr.  Grulliver,  in  the  Edinburgh  Medical  and  Surgical  Jour- 
nal, No.  128,  July,  1836,  et  seq.,  has  written  very  fully  on 
this  subject  of  interstitial  absorption  ;  and  has  adduced  cases 
which  we  would  copy,  if  our  limits  would  allow.  He  shows, 
by  his  specimens,  that  the  head  is  enlarged  at  its  lower  part ; 
that  these  cases  may  occur  in  young  persons  ;  that  it  is  not 
disease  of  the  joint,  from  the  fact  that  there  is  no  anchylosis ; 
and  that  the  cartilages  are  not  involved.  The  cases  of  John 
Lynn,  J.  McGj-ath,  and  J.  Fox,  etc.,  are  adduced,  and  the 
specimens  preserved  from  autopsies.  We  have  abundant 
evidence  of  interstitial  absorption  occurring  from  contusion  in 
persons  like  this  old  maid,  and  Mr.  G-ulliver  says  this  short- 
ening may  take  place  as  rapidly  as  in  five  or  six  days.  Now, 
Prof.  Parker's  specimen  corresponds  to  the  facts  we  have 


31 

given : — 1.  There  is  a  ridge  formed  along  the  lower  part  of 
the  neck,  as  Sir  Astley  Cooper  states,  occurs  in  these  cases  of 
interstitial  absorption.  2.  There  is  the  buttress  of  bone  shoot- 
ing up  from  the  shaft  into  the  head  as  a  means  of  support ;  this 
is  clearly  shown  by  comparing  the  two  specimens,  the  one 
from  the  well  limb,  and  the  one  from  the  contused  limb. 

3.  There  was  a  contusion  sufficient  for  an  exciting  cause. 

4.  This  occurs  in  one  limb  and  not  in  the  other,  as  shown  in 
the  case  of  J.  Fox,  reported  by  Gulliver,  where  one  limb 
was  in  every  respect  natural,  and  iu  the  other  interstitial  ab- 
sorption had  taken  place.  This,  we  believe,  is  the  case  in 
Prof.  Parker's  specimen.  If  this  specimen  is  in  reality  a 
fracture,  it  was  most  probably  partly  extra-capsular ;  if  not, 
it  was  a  case  of  interstitial  absorption. 

I  have  thus  reviewed  all  the  cases  of  supposed  osseous 
union.  All  of  them  are  defective  in  points  of  great  import- 
ance ;  no  one  of  them  places  the  question  beyond  a  reasonable 
doubt,  and  it  should  be  remembered  that  these  are  the  choice 
specimens  of  all  Europe  and  America. 

There  is  a  single  point  more  worthy  of  notice  ;  it  is  the 
extreme  difficulty  there  appears  to  be,  in  all  these  specimens, 
of  deciding  whether  they  are  intra-capsular,  or  only  partly 
within.  The  mere  fact  that  a  surgeon  of  such  eminence  as 
Prof.  Mussey  should  have  been  misled,  and  should  have  been 
so  deceived  as  to  take  a  specimen  across  the  Atlantic,  to  con- 
vince Sir  Astley  Cooper  of  the  possibility  of  the  ossific  union 
of  intra-capsular  fractures,  by  whom  it  was  conclusively 
shown  that  he  was  in  error,  is  sufficient  to  prove  the  difficulty 
of  deciding  on  these  specimens.  All  such  specimens  should 
be  preserved  in  the  wet  state  with  the  capsule  still  attached, 
when  there  could  be  no  doubt  of  their  character. 

The  argument  may  be  thus  summed  up: — 1.  It  is  abso- 
lutely impossible  to  form  a  certain  and  unmistakable  diagnosis 
of  all  these  fractures  during  the  life  of  the  patient.  2.  That 
the  probabilities  are  all  against  union  by  bone,  from  lack  of 
nourishment  to  the  fractured  parts  of  the  head,  from  impos- 
sibility of  perfect  rest,  and  from  synovitis.  3.  The  argument 
from  the  analogy  of  fractures  of  the  patella,  olecranon,  etc.,  is 
an  argument  against,  instead  of  for,  osseous  union.  4.  Cases 
where  every  circumstance  was  favorable  to  union,  if  any  frac- 
tures of  this  kind  could  unite,  yet  which  failed  to  unite.  5. 
The  cases  given  to  prove  this  union  not  having  proved  it. 

The  treatment  of  these  cases  is  obvious.  It  has  been  shown 
that  a  positive  diagnosis  can  not  be  formed.    It  may  be  a  case 


32 

of  those  kinds  which  do  have  a  bony  union.  The  patient  is 
entitled  to  the  benefit  of  this  chance.  If  his  age  and  health 
will  permit,  the  straight  splint  should  be  used ;  while,  at  the 
same  time,  the  surgeon  should  protect  himself,  by  showing 
the  patient  and  his  friends  what  an  unfavorable  result  there 
may  be.  If  the  fracture  is  impacted,  it  should  by  all  means 
be  kept  in  the  impacted  state,  and  all  attempts  to  extend  the 
limb  to  its  proper  length  should  be  abstained  from. 

If  the  patient  is  past  the  prime  of  life,  or  of  enfeebled  con- 
stitution, then  the  double  inclined  plane  splint  should  be  used ; 
and  if  the  patient  can  not  bear  that,  then  simply  let  the  limb 
rest  over  a  pillow. 


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